Provider Demographics
NPI:1396237301
Name:DIAZ, MIRNA ESANIZ
Entity type:Individual
Prefix:
First Name:MIRNA
Middle Name:ESANIZ
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10407 FALCON PARC BLVD APT 304
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5560
Mailing Address - Country:US
Mailing Address - Phone:787-454-5553
Mailing Address - Fax:
Practice Address - Street 1:10407 FALCON PARC BLVD APT 304
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-5560
Practice Address - Country:US
Practice Address - Phone:787-454-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD232-545-74-718-0OtherDRIVERS LICENSE